- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.17 / $38.71 / $47.12
| Professional | | $33.17 | $38.71 | $47.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.80 / $364.52 / $455.46
| Facility | | $91.80 | $364.52 | $455.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.57 / $90.57 / $90.57
| Professional | | $90.57 | $90.57 | $90.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.54 / $38.63 / $49.10
| Facility | | $31.54 | $38.63 | $49.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.18 / $39.39 / $52.57
| Professional | | $31.18 | $39.39 | $52.57 |